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(1) The prevalence of juvenile rheumatism is shown by the incidence of heart disease in 1·5 to 2 per cent. of urban elementary school children. The annual mortality from rheumatic heart disease is probably about 20,000 deaths a year.
(2) The age-incidence is due to the three factors of tonsillitis, exposure, and the diminished resistance to infection of childhood. Where these three factors overlap we get the heavy incidence of the infection. The class-incidence shows a rheumatic stratum of society in the upper poorer classes. The disease is therefore not a “poverty disease” strictly so-called; some added factor is also at work.
(3) Juvenile rheumatism is clearly an environmental disease, for if the children of the poor are transported from their homes to residential schools they remain free from rheumatic infection. What is the factor at work amongst the poor which produces the disease in their own homes? The evidence that cold damp houses have an important influence in producing juvenile rheumatism is considerable. Overcrowding seems to protect to some extent, owing to the prevention of cold. The environmental causes of the disease must centre largely round the production of tonsillar infection.
(4) The organized effort needed to prevent and control juvenile rheumatism consists in increased attention to housing conditions; increased endeavour in early detection by the School Medical Service; increased supervision by hospitals and practitioners of their rheumatic patients; and increased accommodation for prolonged treatment of heart disease.